Previous Pacemaker Research Articles

Predictors of permanent pacemaker implantation after ACURATE neo transcatheter heart valve implantation.

Rates of permanent pacemaker implantation (PPI) have been low using the self-expanding ACURATE neo device, but data regarding risk factors of PPI for this specific device are scarce. The study cohort consisted of patients (n=1000) with severe aortic stenosis undergoing transfemoral transcatheter aortic valve implantation (TAVI) using the ACURATE neo prosthesis in our center between May 2012 and December 2019. For the present analysis, we excluded patients with previous permanent pacemaker (n=110), high-grade AV block prior to TAVI (n=3), and patients requiring conversion to surgical valve replacement (n=4) or the implantation of a second prosthesis as valve-in-valve (n=15). Preexisting conduction abnormalities were determined, and the implantation depth of the prosthesis was measured on final angiography. Differences across quartiles based on the original consecutive cohort were analyzed with respect to implantation depth and PPI rate. Predictors of PPI were identified using logistic regression. The PPI rate was 10%. Preexisting AV block I°, right bundle branch block (RBBB), and the implantation depth were independent predictors of PPI. Across quartiles, the implantation depth differed significantly with lowest values in the last quartile, whereas differences of PPI rates across quartiles were not statistically significant, but showed a notable decrease in the last quartile. Preexisting RBBB, AV block I°, and low implantation depth were independent predictors of PPI following TAVI using the ACURATE neo device. Instead of deliberately aiming at a high position, avoidance of a low implantation depth may represent a reasonable compromise to reduce the rate of PPI without increasing the risk of malpositioning.

Pre-admission cardiac arrest in ST-segment elevation myocardial infarction: incidence, predictors and related outcomes

Abstract Background/Introduction ST segment elevation myocardial infarction (STEMI) is a frequent cause of Cardiac Arrest (CA), and early percutaneous coronary intervention is associated with increased hospital survival in these patients. Despite constant improvements in out-of-hospital CA management, survival remains low. Purpose Our aim was to assess pre-admission CA incidence, predictors and related outcomes in patients admitted with STEMI. Methods We prospectively included 1083 patients admitted with STEMI in a tertiary university hospital in southern Brazil between March 2011 and October 2019. All patients were submitted to emergency coronary angiography. Baseline characteristics, details of the procedure, reperfusion strategies, and in-hospital outcomes were evaluated. Results Mean age was 60.8 years (± 12), 66.2% were male, 62% had hypertension and 25.3% had diabetes. Pre-admission CA was present in 104 (9.8%) patients. Patients with CA had more frequently previous myocardial infarction, temporary pacemaker, smoking and Killip 3 or 4 on admission, and shorter pain–to-door time than patients without CA. In addition, CA patients had a higher incidence of periprocedural CA, cardiogenic shock and periprocedural and in-hospital mortality. In multivariate analysis, age (RR= 0.96, p=0.001), anterior MI (RR=1.67, p=0.04) smoking (RR=0.57, p=0.04), previous ASA use (RR=0.40, p=0.02), Killip 3 or 4 (RR=14.71, p<0.001), temporary pacemaker (RR 2.53, p=0.01), pain-to-door time (RR=0.99, p=0.017) were independently associated with CA. Non Shockable Rhythm (RR=7.37, p=0.017), ROSC duration (RR=1.05, p=0.02) and cardiogenic shock (RR=31.2, p=0.003) were independent predictors of mortality among patients admitted with CA. Conclusion In this cohort of consecutive patients admitted with STEMI, pre-admission CA incidence was greater than seen in literature. Cardiogenic shock and in-hospital mortality were more common in patients admitted with CA, which may in part explain our higher rate of overall in-hospital mortality. Non shockable rhythm, increased ROSC and cardiogenic shock were independent predictors of mortality among patients admitted with CA. Understanding these characteristics may help taking measures to lower mortality rates. Funding Acknowledgement Type of funding source: None

Impact of mitral annular calcification associated mitral stenosis on clinical outcomes in patients undergoing transcatheter aortic valve implantation

Abstract Introduction Mitral annular calcification (MAC) is a common finding in patient undergoing transaortic valve implantation (TAVI) and can cause significant mitral stenosis (MS). Purpose To assess the impact of MAC associated with significant MS (MAC-MS) on clinical outcomes following TAVR. Methods Consecutive patients undergoing TAVI in our institution between January 2008 and May 2018, were evaluated. All echocardiogram exams before intervention were analysed to identify the presence of MAC and MAC was confirmed on computed tomography (CT) scans. Patients were included in the MAC group if there was any calcification on the mitral annulus on CT scan. Severe MAC was considered as calcification of the mitral annulus involving over 50% of the circumference. Patients with a mitral mechanical valve or bioprosthesis and without CT scan available to confirm MAC were excluded (n=62). MAC-MS was defined as the association of MAC and a mean transmitral gradient over 5 mmHg. Results Among 1177 consecutive finally included patients, 504 (42.8%) had MAC and 85 had a MAC-MS (7.2%, 16.9% among the MAC population). Compared to MAC without MS (MAC non-MS group) and non-MAC patients, patients with MAC-MS were more frequently women (p<0.0001), had a greater BMI (p=0.002), more previous pacemaker implantation (p=0.035), smaller indexed aortic valve area and left ventricular end systolic diameter (p=0.019 and p=0.038). At 30-days after TAVR, there were no differences in stroke, major vascular complication and pacemaker implantation between groups. However, MAC-MS patients had higher rates of tamponade [Odd Ratio adjusted 3.12, 95% confidence interval (CI) 1.08–9.07, p=0.036] and mortality [Adjusted hazard Ratio (HRa) 2.83, 95% CI 1.39–5.76, p<0.005] after adjustment on baseline characteristics. At 1 year, patients with MAC-MS had a higher risk of death [19 (22.1%) vs. 142 (13%); HRa 1.83, 95% CI 1.14–3.03, p=0.01] compared to MAC non-MS and non-MAC patients. Severe MAC was not a predictor of 1 year mortality. Conclusions Mitral stenosis due to mitral annular calcification is infrequent in patient undergoing TAVI but is associated with higher early and mid-term mortality. Funding Acknowledgement Type of funding source: None

Pacemaker implantation after balloon- or self-expandable transcatheter aortic valve replacement in patients with aortic stenosis

Abstract Background The incidence of conduction abnormalities requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) with different devices available in recent years remains a matter of debate. Methods Based on the administrative hospital-discharge database, we collected information for all patients treated with TAVR between 2010 and 2019 in France. We compared the incidence of PPI after TAVR according to the type and generation of valve implanted. Results A total of 49,201 patients with aortic stenosis treated with transcatheter aortic valve replacement (TAVR) using the balloon-expandable (BE) Edwards SAPIEN valve or the self-expanding (SE) Medtronic CoreValve were found in the database. Patients treated with early BE or SE valves had higher Charlson comorbidity and frailty indexes than those treated with later BE or SE valves, and slightly higher EuroSCORE II. Patients treated with SE valves had higher rates of previous pacemaker or defibrillator than those treated with BE valves. Mean (SD) follow-up was 1.2 (1.5 years) (median [interquartile range] 0.6 [0.1–2.0] years). PPI after the procedure was reported in 13,289 patients, among whom 11,010 (22.4%) had implantation during the first 30 days (figure 1). In multivariable analysis, using early BE TAVR as reference, adjusted OR (95% CI) for PPI during the first 30 days was 0.88 (0.81–0.95) for latest BE TAVR, 1.40 (1.27–1.55) for early SE TAVR and 1.17 (1.07–1.27) for latest SE TAVR. Compared to early BE TAVR, adjusted HR for PPI during the whole follow-up was 1.01 (0.95–1.08) for latest BE TAVR, 1.30 (1.21–1.40) for early SE TAVR and 1.25 (1.18–1.34) for latest SE TAVR. Conclusion In patients with aortic stenosis treated with TAVR, our systematic analysis at a nationwide level found higher rates of PPI than previously reported. BE technology was independently associated with lower incidence rates of PPI both at the acute and chronic phases than SE technology. However, this was less apparent than previously reported in this large analysis of unselected patients seen in “real life” practice. Recent generations of TAVR were not independently associated with different rates of PPI than early generations during the overall follow-up. Funding Acknowledgement Type of funding source: None

Left atrial strain as a pre-operative prognostic marker for patients with severe mitral regurgitation

BackgroundIn patients with severe mitral regurgitation (MR), additional echocardiographic indices could be helpful to optimize surgical timing before irreversible left heart myocardial dysfunction has occurred. We investigated the correlation of left atrial (LA) strain by speckle tracking echocardiography with prognosis after mitral surgery for severe MR, and its association with LA fibrosis. Method71 patients with primary severe MR undergoing pre-operative echocardiographic assessment were initially enrolled. Exclusion criteria were: other valvular disease>moderate, history of coronary artery disease, heart failure (HF), hypertrophic cardiomyopathy, left bundle branch block, previous pacemaker implantation, heart transplantation, poor acoustic window.The primary endpoint was the occurrence of composite events (HF and mortality); the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10 class). LA fibrosis was assessed by atrial biopsy specimens in a subset of patients. ResultsOf 65 eligible patients, the primary endpoint occurred in 30 patients (medium follow-up: 3.7 ± 1 years for event-group, 6.8 ± 1 years for non-event group). After Kaplan-Meier analysis, peak atrial longitudinal strain (PALS) provided good risk stratification (5-year event-free survival:90 ± 5% for PALS≥21% vs 30 ± 9% for PALS<21%, p < 0.0001); it was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was also an association between PALS and the secondary endpoint (NYHA: r2 = 0.11, p = 0.04; Borg CR10: r2 = 0.10, p = 0.02) and an inverse correlation between PALS<21% and LA fibrosis (r2 0.80, fibrosis: 76.6 ± 20.7% vs 31.9 ± 20.8%;p < 0.0001). ConclusionsGlobal PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.

P564Silent cerebral ischemic lesions after left-sided ablation for paroxysmal supraventricular tachycardia

Abstract Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusion-weighted magnetic resonance imaging (MRI), with an incidence between 1% and 40%. Recent studies have shown that these cerebral lesions can occur after radiofrequency ablation for left ventricular extrasystole. Risk of these lesions in conventional ablation has not been evaluated. Aim of this study was to investigate silent cerebral ischemic lesions following left-sided conventional ablation. In a prospective study 296 consecutive patients scheduled for paroxysmal supraventricular tachycardia (PSVT) ablation were screened, and 26 patients meeting study criteria were enrolled. Patients were excluded for age under 18 years or over 80 years, clinically significant neurovascular or valvular disease, proven left atrial thrombus, thrombophilia, previous pacemaker or ICD implantation, documented paroxysmal atrial fibrillation, or any contraindication to MRI. Participants underwent cerebral MRI 24 hours prior and after the ablation, in case of new ischemic lesions a repeated MRI was planned within 3-6 months. Two sequences were used, a 3D T2-weighted fluid-attenuated inversion recovery (FLAIR) and an axial diffusion-weighted (DW) sequence. By definition acute lesions appear as hyperintensities on the postprocedural diffusion-weighted images which correlate with the hypointense signals on the apparent diffusion map and can not be detected on the preprocedural images. Patients were planned to be divided into three groups patients with and without silent cerebral ischemic lesions who underwent left-sided ablation, and a control group undergoing only right-sided ablation. Groups were compared based on clinical and procedural characteristics. The mean age was 43.9 ± 17.3 years, 42% (n = 11) were men, 35% (n = 9) had a history of hypertension. In all groups radiofrequency energy was used and the ablation was performed with a 4 mm tip non-irrigated catheter. In case of a left-sided procedure left atrium was approached by transseptal puncture controlled by intracardiac echocardiography. Before the transseptal puncture intravenous heparin was administered. Activated clotting time was aimed to be 200-300 seconds. None of the postprocedural MRI in the left-sided or the right-sided group revealed any evidence of new cerebral ischemic lesions. Mean procedural time of left-sided ablations was 176.9 ± 74.7 minutes which was significantly longer (p = 0.0077) compared to the right-sided procedures with 132 ± 72.2 minutes total time. Mean left atrial procedural time was 69.1 ± 7.8 minutes, average ACT was 265 ± 28.2 seconds. No silent ischemic cerebral lesions were detected by MRI after catheter ablation of left-sided PSVT substrate in comparison with the historical population undergoing ablation for atrial fibrillation or ventricular extrasystole. Presumably, cerebral lesions occur at a lower rate or might not appear at all after these less complex procedures.

Analysis of length of stay after transfemoral transcatheter aortic valve replacement: results from the FRANCE TAVI registry.

Currently, there are no recommendations regarding the minimum duration of in-hospital monitoring after transfemoral (TF) transcatheter aortic valve replacement (TAVR) and practices are extremely heterogeneous. We, therefore, aimed to evaluate length of stay (LOS) and predictive factors for late discharge after TF TAVR using data from the FRANCE TAVI registry. TAVR was performed in 12,804 patients in 48 French centers between 2013 and 2015. LOS was evaluated in 5857 TF patients discharged home. LOS was calculated from TAVR procedure (day 0) to discharge. The study population was divided into three groups based on LOS values. Patients discharged within 3days constituted the "very early" discharge group, patients with a LOS between 3 and 6days constituted the "early" discharge group, and patients with a length of stay > 6days constituted the "late" discharge group. The median LOS was 7 (5-9)days and was extremely variable among centers. The proportion of patients discharged very early, early, and late was 4.4% (n = 256), 33.7% (n = 1997), and 61.9% (n = 3624) respectively. Variables associated with late discharge were female sex, co-morbidities, major complications, self-expandable valve, general anesthesia, and a significant center effect. In contrast, history of previous pacemaker was a protective factor. The composite of death and re-admission in the very early and early versus late discharge groups was similar at 30days (3.3% vs. 3.5%, p = 0.66). LOS is extremely variable after TF TAVR in France. Co-morbidities and complications were predictive factors of late discharge after TAVI. Interestingly, the use of self-expandable prosthesis and general anesthesia may also contribute to late discharge. Our results confirm that early discharge is safe.

Unplanned Thirty-Day Readmission After Alcohol Septal Ablation for Hypertrophic Cardiomyopathy (From the Nationwide Readmission Database)

Alcohol septal ablation (ASA) is indicated for symptomatic hypertrophic cardiomyopathy (HC) patients. We sought to analyze the incidence of the 30-day readmission rate, predictors, causes of readmission, and incremental healthcare resource (cost and length of stay) utilization after ASA. Nationwide Readmission Database from 2010 January to 2015 September was queried to identify 30-day unplanned readmission after ASA for HC by using the International Classification of Disease, 9th Revision, Clinical Modification. Those readmitted were similar in terms of age and sex but had higher burden of co-morbidities compared with those not readmitted within 30-days. The 30-day unplanned readmission rate was 10.4% (511/4,932) after ASA. Readmissions lead to an additional mean hospitalization cost of 8,433 US dollars and mean of 4.9 days of length of stay. Predictors of 30-day unplanned readmission were liver disease (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 1.22 to 5.59), renal failure (aOR 2.30, 95%CI 1.52 to 3.50), previous myocardial infarction (aOR 1.97, 95%CI 1.16 to 3.33), previous pacemaker (aOR 1.50, 95%CI 1.09 to 2.08), atrial fibrillation (aOR 1.43, 95%CI 1.08 to 1.89), Medicaid (aOR 1.74, 95%CI 1.12 to 2.68), and weekend admission (aOR 1.75, 95%CI 1.12 to 2.75). Common reasons for readmissions were atrial fibrillation (12.6%), acute on chronic systolic heart failure (12.6%), paroxysmal ventricular tachycardia (6.4%), atrioventricular block (4.9%), and HC (3.0%). Unplanned readmissions after ASA occur in patients with higher burden of co-morbidities and are mainly caused by cardiac etiologies.

Predicting the risk of late futile outcome after transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) risk assessment is still developing and mostly concerned with mortality in the periprocedural period. We therefore sought to develop and then validate a score to predict 1-year adverse outcome. Patients that underwent TAVI for severe AS in the Israeli registry. Patients with unsuccessful/suboptimal implantation were excluded. The cohort was split to derivation/validation cohorts by a ratio of 70:30. The outcome was defined as 1-year composite of mortality, stroke, and no improvement in NYHA class (vs. baseline). Logistic regression was used to fit the prediction model. Out of 2,440 patients meeting inclusion criteria, 276 were excluded, leaving 2,160 patients for both cohorts. At 1 year, 299 (14%) patients experienced the adverse ("futile") outcome. The derived prediction model included mean aortic valve (AV) gradient, previous pacemaker, previous oncological disease, need for diuretics, baseline NYHA class, hemoglobin and creatinine levels, and nonfemoral access site. The model's area under the curve (AUC) was 0.69 in the derivation and 0.70 in the validation cohort. Performance of other scores in the validation cohort were lower (0.60 for STS, 0.55 for Euroscore2, 0.56 for TVT score, and 0.53 for TAVI2-score, p = .03). Based on three risk tiers, patients had a low risk (20/306, 7% futility), a medium risk (50/304, 17%), and high risk (18/37, 49%) for futility. The TAVI futility risk model can be used to provide further insight regarding prediction measures and/or patients' outcomes outside of the periprocedural period (NCT02023060).

Novel Anatomic Predictors of New Persistent Left Bundle Branch Block After Evolut Transcatheter Aortic Valve Implantation

New persistent left bundle branch block (NP-LBBB) has been associated with adverse outcomes after TAVI but few predictors thus far reported. We sought to identify predictors of NP-LBBB after TAVI with EvolutR/PRO (ER/EP). From 1/2016 to 4/2019, 544 patients from 2 centers underwent TAVI with Evolut (54% ER, 46% EP) for severe native aortic stenosis. Patients with previous LBBB and pacemaker were excluded. Aortic root analysis was performed using 3Mensio Valves Software and membranous septal length (MSL) was determined using the standard coronal view. Clinical, anatomic and procedural characteristics of 396 Evolut were analyzed and predictors of NP-LBBB were identified. Valve Academic Research Consortium-2 outcomes were reported. At discharge, NP-LBBB was seen in 76(19.2%) patients. NP-LBBB in Evolut was associated with implant depth at left coronary cusp (p = 0.004) and 34 mm ER (p = 0.026). Independent predictors of NP-LBBB in Evolut were shorter MSL (odds ratio [OR] = 0.82 per mm septum, 95% confidence interval [CI] = 0.68 to 0.98,p = 0.030), left ventricular outflow tract (LVOT) eccentricity (OR = 1.04 per %, 95% CI = 1.01 to 1.06,p = 0.002), implant depth at noncoronary cusp (NCC) (OR = 1.28 per mm ventricular, 95% CI = 1.11 to 1.48,p = 0.001) and annular perimeter oversizing ≥20% (OR = 2.38, 95% CI = 1.20 to 4.72, p = 0.013). On ROC curve analysis, MSL ≤6.5 mm, NCC depth ≥3 mm and LVOT eccentricity ≥35% were optimal threshold values to predict NP-LBBB. In Conclusion, shorter MSL, LVOT eccentricity, annular oversizing and deeper implant depth are novel predictors of NP-LBBB in Evolut TAVI. Preprocedural CT assessment of aortic root anatomy may help identify patients at risk for NP-LBBB. In such patients, modifying procedural factors such as higher implant and less annular oversizing may reduce the risk of NP-LBBB. Further evaluation of our hypothesis is warranted.

Prevalence, incidence and prognostic implications of left bundle branch block in patients with stable coronary artery disease. An analysis from the CLARIFY registry

The prevalence, and prognostic implication of left bundle branch block (LBBB) patients with stable coronary artery disease (CAD) is unknown. To describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was defined as a QRS complex > 120 milliseconds. Patients with previous pacemaker implantation or defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation. From the 23.457 patients with available data, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2 ± 10.1 versus 63.6 ± 10.4 years, P < 0.0001), history of coronary artery bypass grafting (29.2% vs. 23.7%, P < 0.0001), diabetes (35.1% vs. 28.4%, P < 0.0001), and HF (25.2% vs. 16.8%, P < 0.0001). In multivariate analysis there was no difference in the rate of primary outcome between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). Patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, P < 0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, P < 0.0001) ( Table 1 , Fig. 1 ). The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The majority of newly diagnosed LBBB were not contemporary of myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, but with a higher risk of pacemaker implantation and hospitalization for heart failure. This is the first study reporting such results in a broad population of stable CAD patients.

P330 Blunted heart rate reserve during vasodilator stress echocardiography in diabetic and renal failure patients

Abstract Funding Acknowledgements None Background A blunted heart rate reserve (HRR) during dipyridamole stress echo (SE) is a marker of cardiac autonomic dysfunction associated with poor outcome, independently of inducible ischemia, underlying coronary artery disease (CAD) and beta-blocker therapy. Patients with diabetes and/or renal failure have higher prevalence of underlying autonomic dysfunction. Aim. To assess the value of HRR in patients undergoing dipyridamole SE. Methods We prospectively recruited a sample of 61 patients with known or suspected CAD (mean age 75 ± 10 years; 34 males, 55,7%; 50% on beta-blockers at the time of testing). Coexistent atrial fibrillation or previous pacemaker implantation were considered as exclusion criteria. Three groups were identified a priori: non-diabetic with normal renal function (n = 43, Group 1); diabetics, with normal renal function (n = 14, Group 2); severely impaired renal function on dialysis (n = 4, Group 3). All patients underwent dipyridamole SE (0.84 mg/kg in 10"). Wall motion score Index (WMSI) was calculated with a 17-segment score of left ventricle, each segment scored from 1= normal to 4= dyskinetic. HRR was measured by ECG as the peak/rest HR ratio. Results A positive SE (stress WMSI&amp;gt; rest WMSI) was present in 2 patients of Group 1 (4.7%), 4 of Group 2 (28.6%) and no patient in Group 3. Heart rate was different, although not significant, among the 3 groups both at rest (66.1 ± 11.1 vs 64.6 ± 8.5 vs 79.0 ± 8.0, p = 0.050) and at peak stress (83.8 ± 12.6 vs 75.3 ± 10.3 vs 86.5 ± 11.1, p = 0.059). Of note, HRR was statistically different among groups (1.29 ± 0.20 vs 1.19 ± 0.14 vs 1.09 ± 0.06, p &amp;lt; 0.047; see figure). There was no difference in HRR between patients off and on-beta-blockers (1.19 ± 0.16 vs 1.24 ± 0.24, p = 0.421) and with or without positive SE (1.20 ± 0.14 vs 1.25 ± 0.20, p = 0.530). Overall, HRR ≤ 1.17 (median value) was reported in 39.5% of Group 1, 71.4% of Group 2, and 100% of Group 3 pts (p = 0.024). No significant correlations between HRR and peak WMSI (p = 0.183) or age (0.062) were reported. Conclusion HRR is frequently abnormal in patients referred for SE testing, especially in presence of concomitant diabetes and advanced renal failure. The blunted chronotropic response is a simple, imaging independent marker of cardiac autonomic dysfunction and may usefully complement the conventional evaluation with regional wall motion abnormalities during vasodilator SE. Abstract P330 Figure title: HRR box plots

2211Prevalence, incidence and prognostic implications of left bundle branch block in patients with stable coronary artery disease. an analysis from the CLARIFY registry

Abstract Background The prevalence, and prognostic implication of left bundle branch block (LBBB) in general population and patients admitted for acute myocardial infarction (MI) as been extensively studied. However, data are scarce about patients with stable coronary artery disease (CAD) and it remains unclear whether LBBB is only a marker of a severe cardiomyopathy or an independent predictor of events in these patients. Purpose We aimed to describe the prevalence, incidence and prognostic implications of LBBB in patients with stable CAD. Additionally, we aimed to describe the incidence of newly diagnosed LBBB that occurred without recent myocardial infarction. Methods CLARIFY is an international registry of more than 30.000 patients with stable CAD. LBBB was collected at baseline and at each follow-up visit, and patients were considered to have LBBB if the length of the QRS complex was of more than 120 milliseconds. Patients with previous pacemaker implantation of internal cardiac defibrillator were excluded. The primary outcome was a composite of cardiovascular (CV) Death, MI or stroke, and secondary outcomes included hospitalization for heart failure (HF) or the need for pacemaker implantation. Results From the 23.457 patients with available data regarding LBBB status, 1.041 (4.4%) had LBBB at baseline and 1.237 (5.3%) had at least one LBBB assessed during 5-year follow-up. Only 21 patients with newly diagnosed LBBB overtime, had a documented MI the same year. Compared to patients without LBBB, patients with LBBB had a higher risk profile regarding age (67.2±10.1 versus 63.6±10.4 years, p&lt;0.0001), history of coronary artery bypass grafting (29.2% vs 23.7%, p&lt;0.0001), diabetes (35.1% vs 28.4%, p&lt;0.0001), and HF (25.2% vs 16.8%, p&lt;0.0001) (Table). In unadjusted analysis, patients with LBBB had a higher risk of primary outcome (13.4% vs 8.7%, p&lt;0.0001) and each secondary outcome. In multivariate analysis taking into account several possible confounders, there was no difference in the rate of CV death, MI or stroke between LBBB or no-LBBB patients (adjusted HR 1.04, 95% CI 0.85–1.29). However, patients with LBBB had a higher rate of pacemaker implantation (adjusted HR 2.21, 95% CI 1.55–3.15, p&lt;0.0001) and hospitalization for HF (adjusted HR 1.53, 95% CI 1.25–1.88, p&lt;0.0001) (Figure). Outcomes according to LBBB status Conclusion The prevalence of LBBB in patients with stable CAD was 4.4% and 5.3% with 5-year follow-up. The overwhelming majority of newly diagnosed LBBB were not contemporary of documented myocardial infarction. LBBB was not associated with a higher rate of major adverse cardiovascular events, including all cause mortality but with a higher risk of pacemaker implantation and hospitalization for heart failure. To our knowledge this is the first study reporting such results in a broad population of stable CAD patients. Acknowledgement/Funding None

Outcome in patients undergoing upgrade to cardiac resynchronization therapy: predictors of outcome after upgrade to CRT.

The advantages of upgrade to cardiac resynchronisation therapy (CRT) have not been explored as carefully as the outcomes of de novo CRT implantations. Furthermore selection criteria for patients with the potential to benefit the most from this therapy are unknown. Therefore, we analyzed the long term outcome and its predictors in a real-world cohort receiving a CRT upgrade from previous pacemaker (PM) and defibrillator devices (ICD). We analyzed 86 patients (mean age 68 ± 9years; 89% male) undergoing CRT upgrade procedures. Response to CRT as well as long term patient outcome was analyzed. NYHA class improved in majority of the patients during short term period (61%), and this trend remained constant during long term follow-up (54%). The observed all-cause mortality was 54% with mean survival of 49 ± 4months. 11 patients underwent left ventricular assist device implantation or heart transplantation. In the multivariate analysis, only kidney function assessed by GFR (HR 0.97; 95% CI 0.95-0.99; p = 0.009) and LVEF (HR 0.92; 95% CI 0.87-0.97; p = 0.002) remain predictors for mortality. Patients who undergo an upgrade procedure to CRT demonstrate a significant response rate assessed by improvement in NYHA class, with initial baseline parameters such as LVEF and kidney function remaining significant predictors for mortality.

Prevalence of and Risk Factors for Permanent Pacemaker Implantation After Aortic Valve Replacement

Damage to the cardiac conduction system requiring permanent pacemaker implantation is a complication of aortic valve replacement (AVR) that may importantly affect quality of life. We investigated the prevalence of and preprocedure risk factors for new permanent pacemakers after surgical (SAVR) and transcatheter AVR (TAVR) at a single institution. Preoperative variables and baseline electrocardiograms were reviewed for 5807 patients undergoing elective SAVR, with or without coronary artery bypass grafting, and 1292 undergoing TAVR, with or without percutaneous coronary intervention, from 2006 to 2017 at Cleveland Clinic. Patients with previous permanent pacemakers were excluded. Risk factors for permanent pacemaker implantation were identified using multivariable logistic regression analysis. New permanent pacemakers were implanted in 151 (2.6%) after SAVR and in 125 (9.7%) after TAVR (whole group SAVR vs TAVR, P <.0001). Risk factors forpacemaker implantation after TAVR included preoperative conduction disturbances and type of prosthesis (SAPIEN, 9.5%; SAPIEN XT, 4.8%; SAPIEN 3, 10% [Edwards Lifesciences, Irvine, CA]; CoreValve, 30% [Medtronic, Minneapolis, MN]; and other TAVR, 10%). There were no reliable risk factors for pacemaker implantationafter SAVR. Bicuspid valves, mechanical vsbioprosthetic valves, higher Society of Thoracic Surgeonsrisk score, and concomitant coronary artery bypass grafting were not associated with elevated risk. At a high-volume institution in the current era, establishing a baseline for pacemaker implantation after AVR is necessary. Preoperative conduction disturbances and transcatheter valve type affect its prevalence. These data provide a benchmark that should be taken into account when considering TAVR in low-risk patients.

Analysis of length of hospital stay after Transfemoral Transcatheter Aortic Valve Implantation: Results from the FRANCE TAVI (FRench Transcatheter Aortic Valve Implantation) Registry

Transcatheter aortic valve implantation (TAVI) is playing a growing role in the management of patients with symptomatic severe aortic stenosis. However, length of hospital stay (LOS) after transfemoral (TF) TAVI remains widely variable. We aimed to evaluate LOS after TF TAVI and the variability of LOS among French centers using data from the FRANCE TAVI registry. TAVI was performed in 12,804 patients in 48 French centers between January 2013 and December 2015. LOS was evaluated in 5,857 (45.7%) patients treated via a TF approach and discharged directly at home. LOS was calculated from TAVI procedure (day 0) to discharge. The study population was divided into 2 groups based on tertile LOS values. The median LOS in the studied population was 7 (5–9) days and was extremely variable among centers. Patients in the lowest tertile (LOS < 6 days, n = 2,233) constituted the “Early Discharge” group, and patients with a length of stay > 6 days ( n = 3,624) constituted the “Late Discharge group”. Variables independently associated with late discharge were comorbidities (history of mitral valve prosthesis, respiratory failure, atrial fibrillation, and severe pulmonary hypertension), complications occurring during or after TAVI (need for a new pacemaker, tamponade, stroke, vascular complications and acute kidney injury), the use of self-expandable valve and general anesthesia with a significant center effect. In contrast, the history of previous pacemaker before TAVI was a protective factor. Finally, we did not observe any significant difference in the rate of death and re-admission in the early versus late discharge groups. LOS remain high after TF TAVI in France and extremely variable. As expected, co-morbidities and complications were predictive factors of late discharge after TAVI. Furthermore, our results suggest that the use of self-expandable prosthesis and general anesthesia also contributes to late discharge.

Transcatheter aortic valve replacement in patients with degenerative calcified rheumatic aortic stenosis: A 10-patient case series

BackgroundTranscatheter aortic valve replacement (TAVR) for patients with rheumatic heart disease (RHD) has not been well-known. This study aimed to assess characteristics and computed tomography (CT) findings of the aortic valve in old patients with RHD and to investigate the safety and efficacy in the patients who underwent TAVR. Methods and resultsOf 352 consecutive patients with severe aortic stenosis (AS) who underwent TAVR at the Sakakibara Heart Institute between 2013 and 2016, 10 patients (2.8%) were considered to have degenerative calcified rheumatic AS by transthoracic echocardiography. Young patients with rheumatic AS without any calcification were not indicated for TAVR in this study. They were likely to have previous pacemaker implantation, atrial fibrillation, anticoagulants, diuretics, reduced ejection fraction, mitral valve involvement, and high pulmonary artery pressure. CT was able to clearly visualize irregular valve thickening, commissure fusion, and a relatively small amount of calcification from the tip of the leaflet to the base of the aortic valve. Mortality at 30 days after TAVR was 0%, with a mean Society of Thoracic Surgeons Score of 7 ± 4%. Device success was 90%, and no patients met the safety endpoint at 30 days. ConclusionsCT was able to visualize the calcified aortic valve in old patients with RHD, and we demonstrate the safety and efficacy of TAVR in this specific population. Care should be taken for procedural success in particular characteristics with marginal calcified aortic valve, anticoagulant use with low body mass index, or concomitant mitral valve disease.

Upgrading patients with pacemakers to resynchronization pacing: Predictors of success

BackgroundThe investigations of predictors of success or failure of cardiac resynchronization therapy were studied previously. Assessment of success in patients already on dual or single pacemakers and upgraded to cardiac resynchronization therapy (CRT) were not extensively studied before. How to select patients in whom this may be the most optimal strategy is unclear. We sought to determine factors associated with success or failure in this group of patients who were already paced for heart block. Methods81 pts were subjected to upgrade to CRT implantation after being on pacemaker. The study was conducted in Germany. Data was presented as Median (Min.–Max.) for abnormally distributed data or Mean ± SD. for normally distributed data. Parameters that revealed no statistical significance in response: Age, sex, EF, diabetes, renal disease, GFR, MR, QRS duration (all above 150 ms), history of ablation, AF recurrence, previous pacemaker, optimization. The following parameters revealed significant influence on response to CRT: Less responders with: Higher C reactive protein (CRP), presence of tricuspid incompetence (TR), presence of pulmonary hypertension (PHN), presence of previous MI, being ischemic vs nonischemic cardiomyopathy (CM) (less responders with ischemic CM). ConclusionsThe findings through light on specific parameters that predict response to upgrade to CRT after usual pacemaker.

Predictors and prognostic impact of new left bundle branch block after surgical aortic valve replacement

Left bundle branch block (LBBB) induces mechanical dyssynchrony that may lead to left ventricular systolic dysfunction. To evaluate the incidence, predictors and clinical impact of new LBBB in patients undergoing surgical aortic valve replacement (SAVR). After exclusion of patients with pre-existing LBBB, a previous pacemaker or a paced rhythm at hospital discharge, 547 consecutive patients undergoing SAVR were included. All-cause death, cardiovascular death and the combined outcome of all-cause death or a first heart failure event were assessed at 3months and 1year. Patients with and without new LBBB were compared. New LBBB occurred in 4.6% of patients after SAVR (compared with 16.4% of patients treated by transcatheter aortic valve implantation during the study period). Previous valve surgery and an immediate postoperative paced rhythm were independent predictors of new LBBB. At 1-year follow-up, there were no significant differences in all-cause death, cardiovascular death, or the combined outcome of all-cause death or a first heart failure event between patients with and without new LBBB. However, new LBBB was associated with a trend towards functional deterioration and more heart failure events at 1year. At 1-year follow-up, new LBBB did not have a significant impact on clinical outcome, but was associated with worse functional status and more heart failure events.

Long-Term Mortality Effect of Early Pacemaker Implantation After Surgical Aortic Valve Replacement

The need for pacemaker implantation is a well-described complication of aortic valve replacement. Not so well described is the effect such an event has on long-term outcome. This study reviewed a 21-year experience at the Mayo Clinic (Rochester, Minnesota) with aortic valve replacement to understand the influence of early postoperative pacemaker implantation on long-term mortality rates more clearly. This study retrospectively reviewed the records of 5,842 patients without previous pacemaker implantation who underwent surgical aortic valve replacement from January 1993 through June 2014. The median age of these patients was 73 years (range, 65 to 79 years), the median ejection fraction was 62% (range, 53% to 68%), 3,853 patients were male (66%), and coronary artery bypass graft operation was performed in 2,553 (44%) of the patients studied. Early pacemaker implantation occurred in 146 patients (2.5%) within 30 days of surgical aortic valve replacement. The median follow-up of patients was 11.1 years (range, 5.8 to 16.5 years), and all-cause mortality rates were 2.4% at 30 days, 6.4% at 1 year, 23.1% at 5 years, 48.3% at 10 years, and 67.9% at 15 years postoperatively. Early pacemaker implantation was associated with an increased risk of death after multivariable adjustment for baseline patients' characteristics (hazard ratio, 1.49; 95% confidence interval, 1.20, 1.84; p<0.001). Early pacemaker implantation as a complication of surgical aortic valve replacement is associated with an increased risk of long-term death. Valve replacement-related pacemaker implantation rates should be important considerations with respect to new valve replacement paradigms, especially in younger and lower-risk patients.